Global Handwashing Day: why we need system-wide action for universal hand hygiene

The theme of Global Handwashing Day this year is “clean hands are within reach”. Yet almost 2 billion people still don’t have access to basic handwashing facilities. In this blog, Sophie Hickling and Om Prasad Gautam discuss the importance of working throughout the hand hygiene system to ensure clean hands really can be within reach for everyone, everywhere.

Handwashing with soap saves lives. It is a highly cost-effective investment that can prevent the spread of infectious diseases in communities, schools and healthcare facilities. However, access to handwashing facilities* and products, such as soap, is severely inadequate. Despite progress, almost two billion people worldwide still don’t have access to basic hygiene services*. This includes 653 million people who don’t have a handwashing facility in their home. Right now, only 13% of countries that report hygiene data are on track to reach the SDG target. For everyone, everywhere to have access to handwashing services* by 2030 global rates of progress need to triple.

There are disparities in access to handwashing services between regions and countries, and between urban and rural areas. In almost all countries, levels of access are lower in rural areas than urban areas. But since 2015 progress in urban areas – which often present complex challenges – has stagnated. There are also wealth inequalities; the poorest people are least likely to have access to handwashing services with soap and water.

Institutions, such as schools and healthcare facilities, that are key to preventing the spread of diseases significantly lack handwashing services, making them potential centres of disease transmission instead. Globally 43% of schools don’t have basic handwashing services (PDF), and 49% of healthcare facilities don’t have a place for handwashing either near or in toilet cubicles, or where care is provided.

Clean hands are essential for health and social development

While there is no question that handwashing with soap is a crucial response to disease outbreaks such as cholera, Ebola and COVID-19, it is also an important means of preventing endemic diarrhoeal diseases and acute respiratory infections (ARIs), which continue to contribute to morbidity and mortality, particularly in low- and middle-income countries (LMICs). In fact, ARIs attributable to inadequate hand hygiene represent 14% of the total ARI disease burden, according to the latest burden of disease report.

Evidence also suggests that handwashing with soap can:

• reduce the risk of diarrheal disease among children under five years old by 30% in LMICs. (If handwashing interventions are consistently delivered as they have been designed, the impact on health would likely be greater. This is consistent with previous studies that report a reduction in the incidence of diarrhoea by between 42% and 47%);
• reduce ARIs in LMICs by about 17%, helping to prevent a large endemic burden of respiratory disease;
• reduce the personal risk of seasonal coronavirus by 36% (PDF);

And good hygiene reduces infection-related infant (under 1 year old) deaths in healthcare facilities by 27% (PDF).

Hand hygiene has long been established as a critical, preventative measure for many diseases. Throughout the COVID-19 pandemic, stakeholders united under government leadership to drive action towards universal hand hygiene. Now, to ensure clean hands are within reach for everyone, everywhere by 2030, this drive and ambition must be maintained.

We need action across the whole hand hygiene system, which must include:

• Leaders championing hygiene by making it a top priority within the national development agenda, articulating an inspirational vision for accelerating progress, setting out a plan and creating the enabling environment to achieve it.
• Clear institutional arrangements with established mandates, roles and responsibilities for hygiene. All hygiene actors from different levels of government, civil society and the private sector need to work together, supported by effective mechanisms for coordination and cross-sectoral integration.
• Policies that set out governments’ visions and strategies for ensuring universal access, as well as ambitious costed national hand hygiene roadmaps and plans that bring different sectors and stakeholders together.
• Financing strategies focused on increasing the quantity and quality of predictable hygiene funding, driving investment against costed hand hygiene plans, and establishing systems for budget tracking and reporting.
• Designing and implementing evidence-based, engaging, motivational yet sustainable and inclusive hygiene behaviour change interventions at scale that protect health systems through fewer disease outbreaks, improved quality of care and increased health seeking behaviours.
• Strong, nationally led monitoring systems that are used in decision making, and to provide the data required to focus resources and investments where they are needed most. Strong monitoring systems also allow for effective and timely review and course correction.

Our work to ensure clean hands are within reach

We work with governments, partners and communities across the hand hygiene system to ensure access to water, sanitation and hygiene services that underpin good hygiene behaviours. In doing so:

• People and behaviours: We take an evidence-based approach to innovate, implement and evaluate hygiene behaviour change intervention in all country programmes. For example, our hygiene response to COVID-19 reached 242 million people multiple times between 2020 and 2023 with uniquely designed hygiene behaviour change interventions.
• Institutions and integrated programming: We advocate for clear and strong institutional arrangements for hygiene. We work with governments to ensure that hygiene behaviour change is integrated into core public health programmes and policies, for example, integrating hygiene into routine immunisation programmes, into ongoing cholera response programmes, or through hygiene in healthcare facilities.
• Policies and strategies: We provided support to the secretariat of the Southern African Development Community (SADC) to develop the SADC Hygiene Strategy 2021-2025 (PDF), which was approved by Ministers of Health across 16 SADC members states and officially launched in September 2022. We continue to provide support for the implementation of the strategy across the region.
  
  As a core partner of the Hand Hygiene for All Global Initiative, we have supported many national governments such as Bangladesh, Ethiopia, Nepal, Nigeria, Pakistan and Zambia to develop costed hand hygiene roadmaps and will support many more. We are also committed to sharing our learning from this process.
• Planning, monitoring and evaluation: We also emphasise the value of reliable data for decision making on hand hygiene, for example, by analysing the state of hygiene in two regions – Southern Africa and West Africa – and by partnering with others to develop the Hand Hygiene Acceleration Framework Tool to help governments assess progress against national plans and prioritise actions to keep them on track.
• Capacity development: We support governments to develop strategies; increase governments’ and partners’ capacities to design, implement and evaluate hygiene programmes; and allocate and advocate funding for sustainable hygiene behaviour change intervention.

We are committed to continuing to prioritise hand hygiene throughout our work and will not stop until everyone, everywhere has access to handwashing services. We call on governments, donors and the private sector to continue prioritising hand hygiene in their policies, programmes and fundings to ensure hand hygiene is within reach for all.

*Definitions

• Handwashing facility = a sink with tap water, buckets with taps, tippy-taps, jugs or basins designated for handwashing. Fixed or mobile. (Note: a shared bucket used for dipping hands is not considered an effective handwashing facility)
• Handwashing service = a handwashing facility with soap and water
• Basic hygiene service = a handwashing facility with soap and water on premises.

This blog builds on the analysis and reflections captured in WaterAid’s policy paper 'Ending the water, sanitation and hygiene crisis together: policy priorities for accelerating progress', which analyses the blockages to progress for water, sanitation and hygiene and sets out policy recommendations for national governments, donors and decision makers to accelerate progress.

Sophie Hickling is Senior Policy Analyst for Hygiene. Om Prasad Gautam is Senior WASH Manager – Hygiene.

Top image: Abida, 10, washes her hands with soap and fresh running water. Jatrabari, Dhaka, Bangladesh. September 2022